Workers' Compensation Appeals

Episode 88: Calloway County workers' comp attorney Jeff Roberts discusses the process for workers' compensation appeals. In his more than 30 years of practice, Jeff as taken several cases all the way to the Kentucky Supreme Court, on appeal. There are a number of types of appeals, which he'll explain in today's episode. Medical Decision Appeals In workers' compensation cases, this is often the first type of appeal that may need to be filed. Kentucky workers' comp provides generous medical benefits for injured workers . The insurance company is required to pay all reasonable and necessary expenses for treatments related to the workplace injury. However, the insurance company can question whether that treatment meets the standard, per the established guidelines. If the treatment has been denied, even though it was ordered by the treating doctor, the request for treatment can be submitted for utilization review. This review of the medical records will be performed by another doctor, although he/she might not actually specialize in that specific area of medicine. Jeff explains that the company handling the utilization process for the insurance company is actually paid by the insurance company. This could lead to a less than objective outcome, at times. If the utilization review determines that the requested treatment should be denied, this opens the door for the first type of workers' compensation appeals. The injured worker and his/her treating doctor have the right to appeal the decision from utilization review. It's possible to appeal on the grounds that the doctor who reviewed the case didn't have the background to properly review the case. For instance, if your orthopedic specialist recommends a surgery, but the case was reviewed by an internist, this can be appealed. The appeal would then be reviewed by a specialist who does focus in the same area of medicine as the treating doctor. This is referred to as a request for reconsideration. At the end of the second review made, the treatment will either be approved or denied. The injured worker and his/her attorney will be able to appeal the determination to the judge, so long as the case itself has not been decided. It's the responsibility of the injured worker and the attorney to file this appeal. However, if the dispute arises after the workers' compensation case has been settled, it's the insurance company's responsibility to appeal the decision. Jeff explains that Kentucky's workers' compensation benefits can last 15 year, and in some cases for a lifetime. The insurance company has a specific window of time to appeal the treatment. If they don't file by the deadline, the treatment will usually be approved fairly quickly. It would be covered by workers' compensation insurance. Appealing the Administrative Law Judge's Decision While the initial claim for workers' comp benefits is active, a decision by the judge may be eligible for a workers' compensation appeal. For instance, if there's a decision the injury wasn't work-related or the severity of the injury doesn't merit a higher level of benefits. These types of decisions can be appealed. Either side can appeal the judge's decision. This could happen if the insurance company feels the benefits being awarded weren't justified by the severity of the injury. These types of workers' compensation appeals are made to the Workers' Compensation Board. This Board is made up of 3 administrative law judges, appointed by the governor and confirmed by the senate. This group will look specifically at whether the original judge followed the law in making his/her decision. It's also possible the judge may have misunderstood the facts, as supported by the evidence. In essence, the Board is looking for judicial error. No new evidence will be submitted to the Board. This appeal is generally based on legal briefs written by the attorneys for each side. Oral arguments are rare, but they can happen. The Worker's Compensation Board can refuse to al

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